MEDICATION AND EMERGENCY CARE FORM
Dayspring Christian Academy
Medication/Emergency Care Policy
(This Form MUST BE returned with your enrollment forms)
Medication in school may only be used on rare occasions and then under the following conditions:
1.
Medication of any kind may NEVER be brought to school with the student. Any medication must be
brought to school by the parent or guardian, in its original container. Written permission and instructions for
administration from a physician must accompany medication. Physician’s Order forms are available from the nurse
and must be completed and signed before administered. Inhalers are to be in the nurse’s office, not with the child
(unless specific agreement has been made between the child, parent, school, and physician). Dayspring Christian
Academy will always make every effort to administer all medications according to a physician’s order. The school
shall not be responsible for reminding the student to come for the medication; the student must be responsible to
appear at the appropriate time. If the medication schedule can be structured around the school day, we would ask
that this accommodation be made. If students will be off campus (field trip, athletic event, etc.), parents are to
arrange with the school nurse, in advance, the plan to administer the medication.
2.
Non-prescription medicines are NEVER to be carried to school by students. In the event that a parent
anticipates a need for Tylenol or Ibuprofen to be administered, the parent must complete a permission form prior to
administration for the current school year. The medication must be brought in by the parent, in its original
container, labeled with: child’s name, dose amount and frequency.
3.
If there is an unexpected need for Tylenol, the parent will be called at the time and must give consent
before non-prescription medicines will be administered. If the parent is unable to be reached medicine will be
given only if there is written permission on file and it and it can be determined it is within the appropriate dosage
schedule to have the medication.
4.
List other medicines the child takes daily. List any adverse reactions with over the counter medicines such
as Tylenol or children’s Ibuprofen.
5.
It is the parent’s responsibility to keep school medical records current. If there is a change in daily
medicines, contact the school immediately by written note to the nurse. This is for the safety of your child
especially, if in an emergency situation, other medicines may be given by the emergency personnel. If any
alteration of daily activity, a physician’s note will be required.
I hereby authorize Dayspring Christian Academy to arrange for medical examination and/or treatment of my child,
________________________________, should an emergency arise at school or on a field trip. It is understood that
a conscientious effort will be made by the school to contact me at the emergency numbers I have provided before
any medical action is taken. In case of emergency, 911 will be called. The choice of hospital may be limited by the
service.
Emergency Medical History and Allergies:
My child has the following medical conditions: ________________________________________________
Name of medications that child is currently taking: ___________________________________________
List all allergies to medications, food, environmental, other: _____________________________________
______________________________________________________________________________________
Type of reaction: ________________________________________________________________________
Usual course of action: ___________________________________________________________________
A copy of this form and other forms such as Health Care Emergency Action Plan may be sent with your child to
ER if available.( for purpose of communication of Parent information and child’s pertinent medical history)
I understand and will adhere to the Dayspring Christian Academy Medication/Emergency Care Policy.
Signature of Parent/Guardian _____________________________________
Date ________________
THIS IS A REQUIRED FORM FOR EACH STUDENT
DAYSPRING CHRISTIAN ACADEMY
MEDICATION PROTOCOL
The school physician has written a doctor’s order for the administration of the medications listed below. If you would like
your child to have permission to receive these medications when necessary, please initial medications below and sign where
indicated: Permission must be renewed in writing every year. Consent may be withdrawn at any time by contacting the
nurse’s office. All medications from home must be brought to the nurse’s office by parent and proper paperwork must be
filled out. This protocol covers only the medication listed below.
A FORM MUST BE FILLED OUT FOR EACH STUDENT SEPERATELY
STUDENT NAME: ____________________________ DOB: _____________
GRADE: _________
I give the school nurse permission to administer the following:
* Ibuprofen (Motrin) ____ *Tylenol (acetaminophen) ____ Calamine lotion ____ Cough drops ____
Bacitracin Ointment ____ *Benadryl (Diphenhydramine Hydrochloride) ____
_____ All of the above
_____ None of the above
*These medications are provided by the parent of each student when taken regularly.
Father’s Name ________________________
Mother’s Name _______________________
Work phone (___) ________________
Work phone (___) ________________
Mother’s cell #: _________________ Father’s cell #: ________________ Home #: ________________
Address________________________________________ city/state ______________________________
Please list all medications your child is currently taking: ________________________________________
_____________________________________________________________________________________
Please list all known allergies your child has: _________________________________________________
_____________________________________________________________________________________
Medical Concerns including any recent illness or surgery? ______________________________________
_____________________________________________________________________________________
Student’s Physician Name _________________________________
Phone ______________________
Name of Health Insurance Co. ____________________________________________________________ Name of Dental
Insurance Co. ____________________________________________________________
I give permission for the school nurse to administer the above medication and share the relevant medical concerns with
appropriate staff if needed. (Including busing and food service personnel)
Father signature: ________________________________________
Date: ______________________
Mother signature: _______________________________________ Date: ______________________
NO MEDICATION WILL BE GIVEN WITHOUT WRITTEN CONSENT ON FILE ALL MEDICATIONS WILL BE
ADMINISTERED AT THE SCHOOL NURSE’S DISCRETION.
For Parent Information Only - DO NOT RETURN
REQUIRED MEDICAL RECORD INFORMATION
The following medical records are due by August 1st to assure entry to school in the fall.
Your child will not be permitted to begin the school year until ALL medical records are up to date.
Please be advised we follow the rules for vaccine requirements in Massachusetts even if you live in RI. Jackie
O’Brien, who is the public health nurse in Attleboro, is available to administer this free of charge if it is
unavailable from your Dr. If you need her services, call her at 508-223-2222.
If your child is new to Dayspring, at any grade level, a copy of the following must be submitted:
•
•
•
•
A current physical exam
Up to date immunization records
An official copy of a birth certificate
A current record of a lead test date for Daycare (1 y/o), Preschool, and Kindergarten students
If your child is participating in a Dayspring Contact Sports Program, you must submit the following:
•
Assumption of Risk Form
•
Sport’s Candidate Form
•
Physical Exam (with a statement from his/her physician that your child may participate in contact
sports
•
A Massachusetts Pre-participation Head Injury/Concussion Reporting Form
If your child is entering 7th grade, you must submit the following:
•
Proof of a Tdap shot (adult tetanus/pertussis booster)
•
Proof of 2 Varicella Vaccines or evidence of having had the Chickenpox
Please remember students may NEVER carry any medications of any type into the school building (Any
exceptions must be arranged with the school nurse in advance). Medications must ALWAYS be delivered to
the office by a parent with the appropriate permission forms on file in the nurse’s office. In most cases, a
physician’s permission will be required as well, particularly for prescribed medications.
Both the MEDICATION PROTOCOL FORM and the *MEDICATION/EMERGENCY CARE FORM must
be completed and submitted by August 1st. Both of these forms must be filled out for each student every year.
Copies of all medical forms are available in the school office or from the nurse. If you anticipate that your
child will need an over-the-counter medication during the school year on a regular basis, you will need to
provide the medication (in its original container). Medications are only administered according to the above
guidelines unless an emergency arises. (A headache is NOT considered to be an emergency)
If your child has a medication that will need to be administered during the school day or requires an
emergency medication such as an epi-pen or inhaler, please have the necessary forms (available in the school
office) filled out by your physician over the summer and personally bring the medication to the nurse at the
start of the school year. One form per medication is required by law. Be sure to check all expiration dates on
medications prior to bringing them.
All medications must be picked up the last week of school. They will be held for one week after school ends.
They will be disposed of if not picked up. Thank you for your immediate attention and prompt response to
these matters. Please keep this page for your future reference.